Improving Diagnosis of Cardiovascular Disease in the Emergency Department Using Cognitive Informatics Tools (New York)

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Acute coronary syndrome (ACS), including acute myocardial infarction and unstable angina, is one of the most common physician-reported missed diagnoses. The majority of ACS patients present to the health care system via emergency departments (EDs), where the rate of missed acute myocardial infarction is up to 4 percent and of missed unstable angina more than 2 percent. The vast majority of diagnostic errors can be attributed to cognitive errors, stemming from the complexity of the health care system. When working memory is overloaded, physicians are distracted and information processing becomes less efficient, such that information is lost from working memory and performance suffers, threatening patient safety. Mental workload is determined by a combination of task demands, environmental contextual factors, and the skill, experience, and attention of the physician. Thus, workflows, facilities, and environments built to improve “cognitive hygiene”--defined as a state of clinical workflow that optimizes physicians’ cognitive capacities to engage in expert diagnostic decisionmaking--should lead to less mental overload. Such an ideal system in the ED would ultimately increase patient safety.

This project, funded under a Mentored Clinical Scientist Research Career Development Award, will use cognitive informatics theory and methodology to develop a patient dashboard that will improve diagnosis of ACS in the ED via improvement of cognitive hygiene.

The specific aims of this project are as follows:

  • To examine how ED physicians seek information and interact with the electronic health record (EHR) to inform diagnosis of patients presenting with possible ACS 
  • To use this analysis to design and develop an ACS patient dashboard in the EHR for ED physicians 
  • To evaluate the usability of the dashboard, first in a simulation setting and then in a clinical setting, and to iteratively improve dashboard content and features 
  • To pilot test a dashboard-based intervention in a clinical setting and evaluate its integration into diagnostic workflow, acceptance by physicians, and impact on physicians’ diagnostic performance 

The researcher’s hypothesis is that an intervention centered on an EHR-based patient dashboard designed to optimize cognitive hygiene surrounding diagnostic decisionmaking workflows for suspected ACS patients will improve ED physician diagnostic performance.

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